Seeking Second Opinions

For many people, receiving a dire diagnosis or a confusing test result triggers the desire for a second opinion. After all, a diagnosis is based upon someone’s interpretation, a radiologist or a pathologist, for example. Second opinions are a logical next step after a serious diagnosis, and most physicians certainly are in favor of them.

“In general, the most important thing is for the patient and their family to be fully informed regarding the condition as well as possible treatment options. If it is necessary to see another provider, I would fully encourage it,” says Boris Arbit, MD, UCLA Division of Cardiology. “However, it is important to keep in mind that with another opinion, one gets another perspective. This may lead to lack of clarity instead of greater clarity that the patient initially sought.”

While there are guidelines that define conditions and disease states, some conditions are notoriously difficult to diagnose. And as recent UCLA research shows, second opinions aren’t always completely objective when the consulting physician is informed of the original diagnosis, which is a common practice.

How Second Opinions May Be Biased

Researchers at UCLA examined how pathologists tasked with offering a second opinion might be influenced by being informed of the first physician’s initial diagnosis. The results were eye-opening.

While pathologists and most physicians may prefer to have information from a first diagnosis, this information can sway their evaluations and even make them less accurate.

For the study, researchers worked with 149 pathologists who interpreted slides from skin biopsies in two phases. The slides were real skin biopsies from 90 different patients with cases ranging from benign biopsies to invasive melanoma.

In the first phase of the study, the pathologists interpreted a set of skin biopsies without knowledge of any other pathologist’s diagnosis of the case. More than a year later, the pathologists were sent the same patients’ biopsies—without being informed that they were the same samples. But during this second phase, the pathologists were provided with another pathologist’s diagnosis of the case for a random set of cases. For the remaining cases, they were told that no first diagnosis was available.

“In other words, the pathologists were providing a second opinion, but they only knew the first opinion diagnosis for a randomly selected subset of the cases,” says lead investigator Joann Elmore, MD, a professor of medicine in the division of general internal medicine at the David Geffen School of Medicine at UCLA, and member of the UCLA Jonsson Comprehensive Cancer Center. “When information on a first opinion was shared, it was always either more or less severe than the pathologist’s own diagnosis in the first phase.”

The Value of Randomization

Since the study team randomized whether or not pathologists saw a first opinion, they could study the impact on pathologists’ second opinion diagnoses. The researchers found clear evidence that pathologists’ second opinions are influenced by knowing a first opinion diagnosis. When interpreting patients’ skin biopsies in the second phase of the study, they were more likely to give a more severe diagnosis when they saw a first opinion that was more severe, compared with not seeing any first opinion diagnosis. Likewise, when receiving a less severe first opinion, the pathologists were much more likely to give a less severe diagnosis.

These trends held true even among the subgroup of physicians who reported in a baseline survey that they are “not at all influenced” by first diagnoses in their own clinical practice. Pathologists could also be swayed even when the diagnosis in their first viewing was accurate.

“The extensive amount of sway noted in this study points to the complexities of the diagnostic process. A concerning finding of this study was that knowledge of the first diagnoses also swayed pathologists away from correct diagnoses,” Elmore says.

Implications for Treatment

The primary concern, according to researchers, is that the patients’ treatment can consequently be inappropriately harsher or it may be inadequate when a consulting second opinion from a physician is swayed towards a more or less severe diagnosis. Both may ultimately harm patient care and treatment outcomes.

According to the study researchers, the idea that “two heads are better than one” should be carefully considered in medical decision making. This study highlighted how important it is to consider and refine the methods of how these two heads come together when making a medical diagnosis.

In a JAMA Dermatology podcast, Dr. Elmore suggested that people ask for an independent interpretation before the consulting physician is told about the original diagnosis.

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